BY PEGGY A. ROSSI, BSN, MPA – AUTHOR AND RETIRED RN/PHN, CCM, ACM-RN, CMAC
I have long considered case managers as the ICU of a healthcare organization’s revenue cycle. As the “silver tsunami” hits your organization, we may all need to think about what we might have to do to preserve our role while also working to help our hospital or organization financially survive. This possibly means changing how we go about our roles, considering what we can delegate to others so we all can work at our highest level, working smarter and more efficiently.
Guys, the silver tsunami is going to hit, and when it does, we will be working with fewer abilities to link patients with the right care; as included in this tsunami will be doctors and many of our peers who will join the ranks of the retired, leaving vacancies at all levels of care. We all know the strain, mentally and physically, we all suffered during the COVID pandemic; let us not go backward and repeat it. Let us put on our thinking caps and develop strategic plans for working smarter.
So, you may ask, what is the silver tsunami? A January 2024 article in Investopedia states, “The silver tsunami means the demographic shift caused by the increasing numbers of older Americans in our society, led by the baby boomer generation born in 1946 to 1964 who are entering their retirement years” (reference 1). Another article by the U.S. Census Bureau stated: In 2022, since the last census of 2020, we have 10,000 baby boomers retiring each day, and by 2030, all baby boomers will be at least age 65. The silver tsunami is not only driven by the number of baby boomers retiring and impacting healthcare, but life expectancy has grown markedly over the last few decades, and we are living longer due to advances in healthcare due to technology and lower birth rates. This same report also indicated that by 2034, older adults will outnumber persons under 18 (reference 2).
While we are living longer, many older folks, including those who serve or will serve as family caregivers, also suffer from a wide variety of chronic illnesses that impact their ability to perform some of the simplest of activities of daily living while also struggling to help a loved one with their care needs. So, as you work with your families on the discharge plan, and if the plan is home, pay close attention to who will be the family caregiver, making every effort to ensure the discharge plan developed includes family caregiver training on complex tasks and the basics needed to help with their loved one’s activities of daily living.
As you work to make changes in how you do discharge planning or case management for your organization, it is critical you review some basic statistics on not only the silver tsunami but also what this means to healthcare in general. In doing so, you need to start with the numbers of aging persons, what this means to our healthcare workforce, and then your ability to link our patients to the right resources and levels of care as their illness or recovery warrants. Not only this, but you must also review the costs of care and average incomes. From these figures, you will see why it is critical that as a discharge plan is developed for our aging population, it must include working closely with those who will serve in the family caregiver role, and this will mean the discharge plan must be started as early as possible so by the time the physician deems the patient stable for discharge, the family caregiver has had training on how to perform the basics of caring for the patient and the importance of self-care for the caregiver.
The goal of this article is to make you stop and think of what might be the cause(s) of why you have so much pressure from the administration to help work on your hospital’s throughput and how you can work smarter to help preserve your role. I cannot imagine the pressure that will be placed on hospital case managers “to move ‘em out” as beds fill up with patients that cannot be linked to the right post-acute care resources. Stop and think about the patients in these beds – they are often those:
- whose families never have had those hard conversations about what is desired at the end of life, the lack of conversations as to who will be a decision maker and how the bills will be paid;
- families who have never prepared for “the what if” as they think Medicare and insurance will pay for the care; or,
- who daily battle the stigma of being intellectually or developmentally disabled, the LGBTQ+, or persons struggling with mental illness. We sometimes lack training on addressing the behaviors, but the most significant lack is the right resources with trained personnel to offer the care they need.
As you review, stop and think about readmissions and the root causes. While some will genuinely be due to the advances or decline in a patient’s medical condition, many result from caregiver burnout or injury as they were never taught the basics of care as we were taught when we assumed our roles. You also need to review the web and some of the amazing statistics that will help validate why we need to change how we do discharge planning. Here you will find articles such as:
- In a November 14, 2023, article, the Kaiser Family Foundation (KFF) discussed the financial and emotional impact of providing and paying for long-term care and how it wreaks havoc on millions of Americans’ lives. This same article indicates that many in the boomer generation face the prospect of exhausting their financial resources as the price tag for care explodes. As such, KFF created an investigative series they call “Dying Broke.” This series was developed using KFF’s polling abilities, analytics and interviews with experts and impacted individuals and their families. This series then examines the challenges facing families and caregivers in navigating long-term care, and it reports:
“The financial and emotional toll of providing and paying for long-term care is wreaking havoc on the lives of millions of Americans. Paid care, either at home or in a facility, is often so expensive that only the wealthy can afford it, and the ongoing shortage of healthcare workers is also worsening the situation” (reference 3).
- The Social Security Administration’s August 2024 projection shows the average Social Security income across the United States is $1,782.74; and, if disabled and under age 65, their income is 1,538.85 per month (reference 4).
- The Pension Rights Center indicates the median income for persons over age 65 in 2022 was $29,740 for individuals, and households, $50,290 (reference 5).
Then, compare these figures to an article by Kale Van Dis and the National Council on Aging (NCOA), who noted the cost of assisted living care will vary widely by location. Still, she goes on to say that the average cost of assisted living across the United States varies from $4.500 monthly to $54,00 annually across the United States (reference 6).
Considering all the above, as possible changes are made in how you do business in whatever organization you work in (facility), you must stop and think – not every patient needs a detailed discharge plan. This is even outlined in the Conditions of Participations (CoPs) for a hospital, with hospitals being one of 20 of the CoPs and CfCs (Conditions for Coverage) healthcare entities must follow if they are to participate and receive federal funding. While the CoPs were first adopted in 1966, significant changes occurred in 2019 when the Centers for Medicare & Medicaid Services (CMS) adopted new rules for their use, with two saying hospitals must:
“Provide a discharge planning evaluation for those identified patients or at the request of the patient, representative, or physician. CMS only requires evaluating patients identified for a discharge plan or when someone requests one. Best practice tells us that all patients should receive a discharge planning evaluation.
“Develop the plan under the supervision of a registered nurse, social worker, or other qualified personnel. Typically, registered nurses or social work case managers complete the discharge planning assessment BUT – CMS now says in the 2019 version of the CoPs. other personnel can complete the assessment under the supervision of the nurse or social worker. If others are used, it is critical to educate these other qualified personnel in the discharge assessment and planning process.”
Thus, as you make your daily rounds or review your caseload for the day, stop and think: Can someone else help you so you all work to your highest potential? Just think, if you can delegate to possibly another person who has been trained to interview those patients who are less likely to need a detailed discharge plan, how efficiently you and your entire department can function. Suppose you can delegate other patients in your caseload to a co-worker. If you can, this then allows you the ability to work with those families and selected trainers (i.e., physical therapists, occupational therapists, respiratory therapy, or nursing) on the development of a more robust and detailed discharge plan, where all facets of care, complex as well as basics of providing care are included, with the family caregiver taught how to perform the basics of care we often neglect to teach. Thus, the goals of a solid discharge plan for training the family caregiver on how to help their loved one will include:
- Training on how to perform or guide their loved one in performance of any or all of the activities of daily living, and just because we have been trained, we must not forget or take for granted others know how to do them; and
- The family caregiver is taught how to perform care without injury to themselves or the loved one, keeping their loved one in the least restrictive environment – home.
Our final goal with any changes we make in handling the influx of the silver tsunami, the consequences of staffing shortages, and the impact all will have on healthcare: We want a win-win for the patient/family caregiver, our organization, and overall healthcare costs.
References
- ‘Silver Tsunami’: Challenges & Opportunities of an Aging Population (investopedia.com)
- By 2030, All Baby Boomers Will Be Age 65 or Older (census.gov)
- Dying Broke: A New Jointly Reported Series on America’s Long-Term Care Crisis from KFF Health News and The New York Times | KFF
- Monthly Statistical Snapshot, July 2024 (ssa.gov)
- Income of Today’s Older Adults – Pension Rights Center
- How Much Does Assisted Living Cost? (ncoa.org)
Peggy Rossi, BSN, MPA, has been a nurse for over 62 years, entering Sacramento State College as one of the first schools in the US to allow a student to graduate with a bachelor of science in nursing degree. To further her education, she graduated from Golden Gate University in 1985 with a master’s in public administration. She was very active in the discharge planning field from the inception of Medicare and Medicaid in 1965, and she has then been active in the field of case management since the early 1980s, when she was hired to be a medical case manager for a major commercial insurer. From these two areas, she found her true career love – serving primarily over the years as director or consultant of discharge planning and case management for health plans, medical groups, and several major tertiary hospitals in the U.S.
After resigning from a major hospital in Sacto, she was immediately hired by the Center for Case Management. In this position she worked as both a consultant and interim director over discharge planning or case management departments of many hospitals across the U.S. Before her retirement in 2021, she was a nurse consultant for one of California’s 21 regional centers, contracted with the CA Department of Developmental Services. During and after the publication of her last text on case management, she continues to contribute to HCPro’s Case Management Monthly, writing articles of key importance to case managers. Her first two nursing texts are Case Management in Healthcare – A Practical Guide (WB Saunders – 1999) and Case Management In Healthcare 2nd Edition (WB Saunders -2003). The text of 2003 won the American Journal of Nursing award for best nursing management text. Her third nursing professional text was written to assist hospitals as they train new staff to the role and is entitled The Hospital Case Management Orientation Manual – (HCPro 2014). Seeing firsthand the void caregivers endure as they are not appropriately prepared for their role, she has now written a book she has dreamed of for years and is engaging in public events as a speaker to help educate caregivers about their rights. This book is available at Barnes and Noble and on Amazon and is in both a hard copy and an e-print. It is titled Caregiver: A Role We Least Expected – Tip and Tidbits to Help in Your Role (Newman Springs Publishing).
Image credit: FOTOKITA/SHUTTERSTOCK.COM